Ayurveda for managing noncommunicable diseases in organisation for economic co‐operation and development: A qualitative systematic review protocol on experiences, perceptions, and perspectives of ayurvedic practitioners and patients

Abstract Background and Aims Ayurveda is a traditional medicine that originated in the Indian subcontinent, and its use remains widespread in the Indian subcontinent, especially for managing noncommunicable diseases (NCDs). It is also becoming increasingly popular in the Organization for Economic Co‐operation and Development (OECD) countries as complementary and alternative medicine. Qualitative research studies have been conducted in various OECD countries to explore the experiences, perceptions, and perspectives of Ayurvedic practitioners and patients with NCDs regarding the usage of Ayurveda for managing these conditions. However, to date, no systematic review on this topic has been published. Therefore, this systematic review aims to synthesize the experiences, perceptions, and perspectives of Ayurvedic practitioners and patients with NCDs on the usage of Ayurveda for managing these conditions in OECD countries. Methods The systematic review will be conducted in accordance with the joanna briggs institute systematic review guideline on qualitative evidence. We will include qualitative research studies conducted among Ayurvedic practitioners or adult patients with NCDs in any OECD member country to explore experiences, perceptions, or perspectives regarding the usage of Ayurveda for managing NCDs. MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), AMED, and Web of Science will be searched to identify published studies. EthOS and ProQuest Dissertations and Theses will be searched to identify unpublished studies. No date or language restrictions will be applied. Initially, a narrative synthesis will be conducted. Where possible, study findings will be pooled using the meta‐aggregation approach.


| Burden of noncommunicable diseases (NCDs) in organization for economic co-operation and development
The Organization for Economic Co-operation and Development (OECD) is an intergovernmental organization with 38 member countries. 1Most OECD nations are high-income countries with a high Human Development Index (HDI). 1 One of the major public health interests of the OECD is to identify, plan, and implement effective interventions to manage NCDs. 2 NCDs are conditions that have long-term health and socioeconomic consequences and often necessitate a need for long-term management. 3,4Due to changes in the population structure, environment, and lifestyle and behavior, the prevalence of NCDs has rapidly increased in many OECD countries. 5Ds are the leading cause of morbidity and poor quality of life in several OECD countries. 5In 2019, compared with the global average of 80%, NCDs accounted for 88% of all years lived with disability (YLDs) in OECD countries. 6In OECD countries, 85% of all disabilityadjusted life years (DALYs) were attributed to NCDs, compared with the global average of 64%. 6Similarly, NCDs are the leading cause of death in many OECD countries, and in 2019, 89% of total deaths in OECD countries were attributed to NCDs, which was higher than the global average of 74%. 6 OECD countries, NCDs cause increased demand for health services, and the high treatment costs lead to increased health expenditures. 5,7,8Furthermore, NCDs in OECD countries cause significant productivity loss due to absenteeism (unable to work due to illness), presenteeism (working less effectively), and early retirement. 5,7,8A comprehensive evaluation in OECD nations reported that compared with individuals who did not report having an NCD in a particular year, those having at least one NCD were less likely to be employed in the following year. 9Moreover, those with at least two NCDs had an even lower likelihood of being employed in the following year and were more likely to retire early. 9

| Ayurveda for NCD management in organization for economic co-operation and development
Ayurveda, which means "knowledge of life," is a traditional medicine that originated in the Indian subcontinent more than 5000 years ago and is one of the oldest medical systems in the world. 10,11It aims to preserve health by following a healthy lifestyle and to manage diseases if they occur. 11Ayurveda is considered a complex intervention, which uses Ayurvedic detoxifying and purifying therapies (e.g., Panchakarma) and Ayurvedic medicines (containing plant-, animal-, or mineral-origin ingredients-single or in combination). 12The mechanism of action depends on the specific therapy or medicine and the health condition in which it is used. 11Ayurveda's use remains widespread in the Indian subcontinent because it aligns with their health beliefs and culture, and as a result, its acceptability, satisfaction, and perceived relief are generally high, particularly among the poor, older, rural, and tribal populations. 124][15] and these texts are followed by Ayurvedic practitioners to manage these conditions in real practice. 16,17[20][21][22][23] For example, a systematic review reported the effectiveness and safety of several Ayurvedic medicines for managing type 2 diabetes mellitus. 18Another systematic review reported the effectiveness and safety of Ayurvedic herbal preparations for managing hypercholesterolemia. 19 Ayurveda is frequently perceived as safe by Ayurvedic practitioners and people. 24However, cases of heavy metal (such as mercury and lead) poisoning have been reported after using some Ayurvedic medicines that contain heavy metals. 25Many Ayurvedic practitioners assert that if the precise heavy metal processing methods, mentioned in Ayurvedic classical texts, are not followed, heavy metal poisoning will most likely occur. 12e World Health Organization (WHO) defines complementary and alternative medicine (CAM) as a broad set of healthcare practices that are not part of a country's own tradition or conventional medicine and are not fully integrated into the dominant healthcare system. 26Ayurveda is considered CAM in many OECD countries. 26,27reover, Ayurveda is now officially recognized in five OECD countries: Colombia, Switzerland, Hungary, Latvia, and Slovenia. 280][31][32][33][34] The spread of Ayurveda in these countries is partially a result of the migration of individuals from the Indian subcontinent to these countries and the growing interest of local people in Ayurveda. 32,34For instance, it has been reported that South Asian migrants in the USA and Canada have used Ayurvedic medicines at some point in the past to treat various medical conditions, including NCDs. 34,35Some other reasons for choosing Ayurveda to manage NCDs in OECD nations are patients'

Key points
• Ayurveda is one of the oldest medical systems in the world.
• The spread of Ayurveda is partially a result of the migration of individuals from the Indian subcontinent to other countries.
• Ancient texts on Ayurveda have vividly described the management of several noncommunicable disease (NCD).
• Systematic reviews of clinical trials have demonstrated the effectiveness and safety of Ayurveda for managing NCDs.
34]36 However, to date, no systematic review on this topic has been published, and this systematic review aims to synthesize these experiences, perceptions, and perspectives.

| Review question
What experiences, perceptions, and perspectives do Ayurvedic practitioners and patients with NCDs have on the usage of Ayurveda for managing these conditions in OECD countries?

| METHODS
The systematic review will be conducted according to the joanna briggs institute (JBI) systematic review guideline on qualitative evidence 37 and reported according to the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guideline. 38The systematic review protocol has been registered with PROSPERO (CRD42023397952).

| Participants
The systematic review will include studies conducted among Ayurvedic practitioners or adult ( ≥ 18 years old) patients with NCDs.

| Phenomena of interest
This review will include studies that explored experiences, perceptions, or perspectives regarding the usage of Ayurveda for managing NCDs.

| Context
This review will include studies conducted in any OECD member country, namely, Australia, Austria, Belgium, Canada, Chile, Colombia, Costa Rica, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Korea, Latvia, Lithuania, Luxembourg, Mexico, Netherlands, New Zealand, Norway, Poland, Portugal, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, UK, and USA. 1 Any study setting will be eligible, such as community, primary care, secondary care, or tertiary care.

| Type of studies
This review will include qualitative research studies that used data collection methods like semistructured interviews, focus group discussions, observational studies, ethnographic studies, documents, case note analyses, or diaries.

| Databases and search strategies
The following databases will be searched for published studies:  1.The search strategies were developed in consultation with a research librarian at the University of Nottingham (UK).Ayurveda and qualitative study design components are based on the search strategies used in previous systematic reviews. 18,39,40The reference list of the included studies and previous relevant systematic reviews will be screened for additional studies.No language restrictions will be applied, and translations will be sought where necessary.Similarly, no date restrictions will be applied.

| Study selection
Following the search, all citations identified will be collated and uploaded into EndNote X9 (Clarivate Analytics) 41 a reference management software.Subsequently, the duplicate citations will be removed.Two reviewers (P.E. and K. C./L. N./M.B.) will independently screen titles and abstracts for eligibility using the systematic review inclusion criteria.Studies identified as potentially eligible or those without an abstract will have their full text retrieved, and their details will be imported into the JBI system for the unified management, assessment, and review of information (JBI SUMARI, JBI). 42Two reviewers (P.E. and K. C./L. N./M.B.) will independently assess the full text of studies against the inclusion criteria.Full-text studies that do not meet the inclusion criteria will be excluded, and the reasons for exclusion will be reported.Any disagreements that arise between the two reviewers will be resolved through discussion.If a consensus is not reached, a third reviewer (K.C./L. N./M.B.) will be involved.or perspectives on the usage of Ayurveda for managing NCDs).Each extracted finding will be supported by a verbatim data excerpt from the study's participants.Where this is not possible, the author's narrative will be extracted.These findings will be reviewed and assigned a level of credibility based on the JBI guideline: 1. Unequivocal: the finding is accompanied by an illustration that is beyond a reasonable doubt and is not open to challenge.
2. Credible: the finding is accompanied by an illustration that lacks a clear association with it and is open to challenge.
3.Not supported: when neither unequivocal nor credible can be applied and when the most notable findings are not supported by the data. 37

| Data synthesis
To uncover any similarities and differences between Ayurvedic practitioners and patients with NCDs in terms of their experiences, perceptions, and perspectives regarding the usage of Ayurveda for managing NCDs in OECD countries, their data will be synthesized separately.Initially, a narrative synthesis will be conducted.Where possible, study findings will be pooled using the meta-aggregation approach. 37,43This will involve the aggregation or synthesis of findings to generate a set of statements representing that aggregation, which will be accomplished by assembling the findings and categorizing them on the basis of their similarity in meaning.Next, these categories will be synthesized to generate a single comprehensive set of synthesized findings.
MEDLINE (Ovid; 1946-present), Embase (Ovid; 1974-present), CINAHL (EBSCOhost; 1961-present), PsycINFO (1806-present), AMED (1985-present), and Web of Science (1900-present).The search for unpublished studies will include EthOS and ProQuest Dissertations and Theses.The search strategies are reported in Table Web ofScience #1 TI= (Australia or Austria or Belgium or Canada or Chile or Colombia or Costa Rica or Czech Republic or Denmark or Estonia or Finland or France or Germany or Greece or Hungary or Iceland or Ireland or Israel or Italy or Japan or Latvia or Lithuania or Luxembourg or Netherlands or Holland or New Zealand or Norway or Poland or Slovakia or Portugal or Slovenia or Spain or Sweden or Switzerland or Turkey or United Kingdom or UK or Britain or Great Britain or England or Northern Ireland or Scotland or Wales or United States or USA or United States of America or Republic of Korea or Democratic People's Republic of Korea or Korea or Mexico or OECD) #2 TI= ("Ayurvedic medicine" or Ayurved* or "traditional medicine" or "complementary medicine" or ((plant* or herb* or medicin* or drug* or therap* or intervention* or extract* or formulation* or preparationProQuest Dissertations and Theses Ayurved* and summary((Australia or Austria or Belgium or Canada or Chile or Colombia or Costa Rica or Czech Republic or Denmark or Estonia or Finland or France or Germany or Greece or Hungary or Iceland or Ireland or Israel or Italy or Japan or Latvia or Lithuania or Luxembourg or Netherlands or Holland or New Zealand or Norway or Poland or Slovakia or Portugal or Slovenia or Spain or Sweden or Switzerland or Turkey or United Kingdom or UK or Britain or Great Britain or England or Northern Ireland or Scotland or Wales or United States or USA or United States of America or Republic of Korea or Democratic People's Republic of Korea or Korea or Mexico or OECD)) appropriate, not applicable (n/a) to that particular study.Any disagreements that arise between the reviewers will be resolved through discussion.If no consensus is reached, a third reviewer (K.C./L. N./M.B.) will be involved.Where possible, all included studies, regardless of the methodological quality assessment outcome, will undergo data extraction and synthesis.